Table 5.

Potential Contributions of EHR Technology to Medication Error Types and Recommendations

Changes in Error Types	Possible EHR-Related Mechanisms	Human Factors Engineering (HFE) Implications and Recommendations
ORDERING
orders with omitted information	- EHR medication ordering screens provide guidance for entering all necessary order-related information. - Hard stop – all required information fields must be filled for order to be signed. - Default dose, route, frequency information for medication orders	- The structure of the EHR interface facilitates entry of required information. However, we need to recognize the potential negative consequences of this structure as well as hard stops (see increase in orders with inappropriate or wrong information). - Hard stops may produce questionable information being entered in the EHR as prescribers are trying to accomplish tasks, sometimes under time pressure. - The provision of default values may reduce omitted information, but may be accepted without sufficient thought [39 40].
wrong drug orders	- Medication selection errors due to pick-lists of medications - Wrong patient - Wrong drug for patient	- Relevant contextual information should be provided during ordering (e.g., current list of medications, previously discontinued medications). - Need for human-centered design of pick lists, including presentation of items on pick list (e.g., need for scrolling, most common medications at top of list) and use of TallMan lettering. - Prescribers could see only one patient at a time, but wrong patient ordering still occurred, possibly related to interruptions. - Provision of clinical decision support (e.g., patient with renal failure) may help to reduce wrong drug ordering for patient. - Making picture of patient visible may help during ordering.
orders with error-prone abbreviations	- Design of EHR technology eliminates error-prone abbreviations.	- The EHR design can eliminate errors at the source. - Need to monitor for re-introduction of ambiguous abbreviations.
illegible orders	- EHR technology eliminates handwriting and makes orders legible.	- The EHR design can eliminate errors at the source.
orders with wrong start or stop times	- The medication order includes default start times for all medication orders and stop times for selected medications. Nurses and pharmacists previously specified start times for medication administration. - Default start times were very soon after the order was entered. Physicians did not always change inappropriate start times and accepted default start times even when not appropriate (for example, a new order is placed to decrease a medication dose with a start time within the hour but the medication dose from the prior order was just administered; so the new dose should start when the next dose was due, not immediately).	- Implementation of EHR technology needs to consider the various roles involved in the medication-management process and clarify who in the process should be responsible, for instance, for scheduling medication administrations. Physicians may be responsible for deciding number of days for a medication order. Deciding on specific start or stop times may be assigned to pharmacists and/or nurses. - Making it more obvious when default start/stop times are assigned and changed may help the prescribers in ensuring adequate consideration of these default values.
duplicate orders	- Identical duplicate orders - Duplicate orders with same medication - Duplicate orders with medication of same therapeutic class [23]. Work system factors that contributed to duplicate orders include [23]: - Multiple clinicians entering orders at the same time on the same patient (e.g., during rounds). - Not being able to see relevant context (e.g., recently placed orders) when ordering. - Duplicate order alerts with high false positives leading to alert fatigue and ignoring true alerts. - Unusable duplicate order alerts.	- It is important to design not only the EHR technology, but also the rest of the sociotechnical work system [11 12]. - Proactive risk analysis should be conducted before implementation [37 38]. - After implementation, continued attention needs to be paid to EHR usability and other HFE issues of continuous technology implementation [41 42].
failure to renew orders	- Requirements to renew orders for certain medications were eliminated.	- A consequence of the elimination of renew orders was the continuation of medications for longer than necessary, e.g., intravenous fluids.
orders with inappropriate or wrong information	- This may be related to the decrease in orders with omitted information. A negative consequence of structure in the EHR interface and of hard stops may be inappropriate or wrong information entered. - Some users may use free-text fields rather than the template sections.	- Any functionality of the EHR technology has potential positive and negative consequences. Therefore, proactive risk analysis needs to be performed before the EHR technology is implemented [37 38]. - After EHR implementation, continued attention needs to be paid to the use of the technology; this is in line with a continuous technology implementation process [41 42].
TRANSCRIPTION
transcription errors	- EHR eliminates need for transcription.	- Whenever appropriate, eliminate or automate steps that are potential sources of error.
DISPENSING
dispensing errors	- More efficient and timely flow of information from prescribers to pharmacy system; therefore, pharmacy dispenses medications more quickly.	- Interoperable health information technology can eliminate inefficiency and errors due to paper processing.
ADMINISTRATION
omitted administrations	- Tighter coupling between time order is placed and scheduled first dose administration time. - This may be related to the increase in orders with wrong start times.	- See recommendations about how to reduce orders with wrong start or stop times, including the need to consider the work system and the medication-management process as wholes.
late administrations	- Increased awareness of medication administration times due to design of technology - This may be related to the decrease in dispensing errors, especially late medication dispensing.	- EHR technology may eliminate inefficiency due to paper processing and support more timely medication administration. - Improvement in one part of the process may help improve a subsequent part of the process.
incorrect documentation of medication administration	- Medication administrations recorded in one EHR component (e.g., respiratory therapy notes) may not be recorded in another component (e.g., MAR).	- Eliminate need for duplicate documentation.